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Based on a review of facility documents, observation, and employee interviews (EMP), it was determined that the facility failed to maintain compliance with all applicable State Regulations.

Titusville Area Hospital was found to be noncompliant with the following State Regulation:

§51.3(d) A health care facility shall submit to the Department architectural plans and blueprints of proposed new construction, alteration or renovation to the facility. The facility shall be submitted at least 60 days before the initiation of construction, alteration or renovation. The Department will review these documents to assure compliance with relevant life safety code and other regulatory requirements. The Department will respond to the facility by either issuing an approval or disapproval or requesting further information within 45 days of receipt of the facility ' s submission. The facility may not initiate construction, alteration or renovation until it has received an approval from the Department.

Based on a review of facility documents, observation, and employee interviews (EMP), it was determined that the facility failed to submit architectural plans and blueprints to the Department at least 60 days prior to the initiation of construction; and further initiated construction, alteration, or renovation prior to receiving approval from the Department.

Findings Include:

Review of a folder of construction-related documents, between 9:42 AM-10:27 AM on March 21, 2017, revealed that the facility completed an ICRA for the Lobby Project on January 17, 2017.

Review of the "Finish Schedule for: Titusville Lobby Date: 2-21-17," revealed:

"Area ... Vestibule G01 ..." work to include renovation/replacement/repaint of flooring, base trim, walls, ceiling, door trim/jams, and lighting.

"Lobby G03," work to include renovation/replacement/repaint of flooring, base trim, walls, curved wall to left of seating area and curved wall to left of seating area and curved wall of chapel, check in desk - countertops, check in desk - body, furniture, ceiling bulkheads, and lighting.

"SPU waiting G06/Reception G07," work to include renovation/replacement/repaint of flooring, base, walls, check in desk-body, check in desk-countertops, ceiling bulkheads, lighting, and furniture.

"Ramp/Corridor down to elevators," work to include renovation/replacement/repaint of flooring, base, walls, accent lighting, handrails/corner guards.

"Bathrooms," work to include renovation/replacement/repaint of flooring, walls, vanity, and lighting.

"Everywhere," work to include renovation/replacement/repaint of lighting - overhead trough lights, window treatments, handrails and corner guards, signage, walls-all, base, and floor.

Review of, "Attachment A Invitation to Bid [OTH1-Other Healthcare Facility] ... Date Issued: October 4, 2016 Date and Time of Bid Deadline: October 24, 2016 at 12:00 noon Job: Renovations - Titusville Area Hospital Lobby ... Label outermost sealed bid package: [OTH1] ..."

Review of, "Attachment B [OTH1] Date October 4, 2016 Job: Renovations - Titusville Area Hospital Lobby ... Area: TAH Lobby ... Scope: Renovations to the lobby of the Titusville Area Hospital will include the following, which are numbered accordingly on the attached print. 1. Remove and replace all flooring within the project area. 2. Remove all wall coverings, prep walls, and paint. 3. Remove all ceiling tiles, level existing ceiling grids, and install new tile. 4. Replace three Formica clad door, stain to match existing two vented doors at the restrooms. 5. Modify display case to create kiosk, install quad power, install single data line. 6. Remove existing restroom fixtures, except toilets, and remove privacy wall; install new casework and counter; install floor tile and wall tile to ¾ height; and paint above. 7. Remove closet to create new access to the women ' s restroom; remove existing door and frame; and install same. 8. Remove and construct new reception desks at the main reception and outpatient areas; each with new identical counters and stone veneer."

Review, at approximately 11:04 AM on March 21, 2017, of "Administrative Notification Policy," revised January 2017, revealed, "... I. Policy Statement Titusville Area Hospital intends to comply with State Regulations (§51.3, §51.4, §51.5) and CMS Regulations (§485.627(b)(1). II. Responsibility ... B. Records of notifications made will be filed in Administrative files and produced upon request. C. Notifications will be made to the appropriate regulatory body in writing and sent by US Mail, facsimile or email as required. ... IV. Procedure A. Consistent with PA Department of Health and CMS regulations, the following notifications will be made: ... 4. Architectural plans and blueprints will be submitted to the Department of Health when new construction, alteration or renovation to the facilities is planned. These materials and notification will be submitted at least 60 days prior to the initiation of construction, alteration or renovation. The hospital understands that it may not initiate construction, renovation or alterations until it has received an approval from the Department of Health. ..."

1. Upon entering the facility, at approximately 9:30 AM on March 20, 2017, a sign was noted on the door outside the facility stating, "Construction Area." The facility Lobby was noted to have an ICRA barrier separating part of the Lobby, new stone veneer finishes on the wall, and missing cove molding at the base of the walls. Additionally, there was a dried, hard, white substance on numerous floor tiles outside the ICRA barrier, and a housekeeper was noted to be scraping the identified substance off one of the floor tiles. White powder was noted to have accumulated on the carpeted surfaces, at the wall bases.

2. In response for a request (during entrance conference on March 20, 2017), from the surveyor, for stamped Lobby project plans, EMP1 stated, at approximately 10:06 AM on March 21, 2017, "[EMP12] thinks what you're looking for is the structural stuff, and they are still waiting for that ... so they went ahead ... they are working on the superficial stuff."

3. An interview was conducted, between 11:15 AM and 11:46 AM on March 22, 2017, with EMP12. When asked when construction in the Lobby began, EMP12 stated, "Early January." When asked if EMP12 was aware of a potential completion date for the project, EMP12 stated, "Not until I get the report back from the state saying that we can start with the major renovation work." When asked when the facility sent plans for the Lobby project to the Plans Review Department, EMP12 stated, "Plans were just sent this week, beginning of this week." When asked who made the decision to proceed without approval from the Plans Review Department, EMP12 stated, "It is my house, so I would say it is my decision. ... I look for guidance, and I'm instructed one way or another how to proceed." When asked what "superficial," is considered for the purpose of the Lobby project at the facility, EMP12 stated, "... painting, simple wall paper removal, ...we put our barriers up. ... ceiling tile, done in stages. ..." When asked what the scope of the project has been to this point, EMP12 stated, "About 80% of it was painting and wall paper, ... lighting. ... Those are all LED lights that are put in there, ... we just replaced the older models with the new ones." EMP12 further confirmed the stone finish is new, and cove moldings were removed. When asked, with the cove molding missing from the bases of the walls, what steps were being taken to protect the drywall from mop water and other substances soaking into the drywall, EMP12 stated, "Absolutely nothing protecting that at all."

Based on a review of facility policies and procedures, observation and employee interview (EMP), it was determined that the facility failed to ensure that the premises were equipped, operated and maintained so as to sustain sanitary characteristics and to minimize all health hazards in the hospital.

Findings include:

Review of facility policy, on March 22, 2017, at approximately 2:45 PM, revealed, Titusville Area Hospital Housekeeping Policy and Procedure Manual, updated 2016, revealed, "... Emergency Room A. General statement of purpose: 1. To provide a clean and safe environment for the patients and all who work here ... 1. Empty, clean and reline baskets ... E. Wet mop all areas. F. Sweep walk off mats prn [as needed]. G. Spot clean walls prn. H. Damp dust all counters, horizontal surfaces and doors. I. Clean sinks, fixtures and restrooms ... The Emergency Area is a constant cleaning task. You must work around the case load. Rooms must be cleaned after each use ... ."

Review of facility policy, updated in 2016, on March 22, 2017, at approximately 2:50 PM, revealed, "... Environmental Services Safety Rules ... 1. check for and report all unsafe conditions, such as: defective equipment, sharp edges, loose floor coverings, loose light fixtures, defective cards/wheelchairs damaged light switch and power outlet covers. Do not attempt to fix any equipment yourself, at any time. Report the situation to your superiors who will arrange for repairs to be made ... Report slipping & tripping hazards to your supervisor promptly ... ."

1. Tour of the Emergency Department (ED) on March 21, 2017, at approximately 9:15 AM, revealed a layer of dust on the top of the Xray light, the top of the blanket warmer, the cupboards, and the shelves located in Room #6.

Continued tour of the ED revealed black finger prints on the overhead light in Trauma Bay #2, dust on the Crash Cart with tape and dirt marks, dust and dirt marks noted on a utility cart in the Soiled Utility Room, black smudge marks on the bottom of the two computers on wheels, and dust on the sharps containers.

The Trauma Area of the ED revealed a crack in the floor tiles that was covered by gray duct tape. The duct tape was noted to be peeling and covered with brown and black marks.

The Nurse Station within the ED revealed a circular area on the floor, where tile was missing, exposing an area of cement where the tile once was.

During an interview on March 21, 2017, at approximately 9:15 AM, EMP38 confirmed the above findings.

2. When shown the dust in the different areas of the ED, on March 21, 2017, at approximately 9:20 AM, EMP40 indicated, "We [Environmental Department] have been short-staffed recently."

3. Tour of the Sleep Lab on March 21, 2017, at approximately 2:50 PM, revealed a layer of dust on the top of a cupboard in Room 225, and a layer of dust was observed above the light in the bathroom.

During an interview, at the time of the Sleep Lab tour, EMP13 confirmed the above findings.